The Coalition to
Protect Patient Choice

A Project
of the
Law Offices
of David Balto
Competitive healthcare is healthcare with choices
Advocacy on consumer healthcare competition issues aimed at lowering prescription drug costs
Health Insurance Mergers Mean...
Higher insurance premiums as the number of national insurers potentially go from five to three.
Less innovative methods of care since insurers will have less need to compete for consumers.
No assurance of coverage, benefit coordination, or other efficiencies and considerations that typically offset competitive harms.
Will Health Insurance Mergers Impact You?
THE FACTS
Today, there are only five national competitors -- UnitedHealth, Anthem, Cigna, Aetna and Humana. This makes health insurance markets already highly consolidated and insurance premiums are increasing because of it. State Insurance Commissioners and Congress are investigating the Anthem/Cigna and Aetna/Humana mergers. The Department of Justice and many State Attorneys General filed suit to block the mergers, on the grounds that they are anticompetitive and will harm consumers. To see the trial documents, click here.
The CPPC believed these mergers should be challenged or patient choice would suffer. In fact, studies have shown previous health insurance mergers resulted in increases ranging from 7% (Dafny) to 13.7% (Guardado). The argument that health insurers drive down health costs has no impact on consumers -- historically, no savings are passed along to consumers. Instead, insurance costs rise for employers, individuals, and families.
The proposed mergers of Anthem and Cigna and Aetna and Humana were ruled anticompetitive in federal court. Thank you to everyone who opposed the mergers and fought to protect consumers and competition!
California
California Consumer Group Comments to Department of Managed Care | 3.4.16
California Consumer Group Comments to Department of Managed Health Care | 1.11.16
Delaware
Delaware Consumer Group Comments to Delaware Deputy Attorney General Kathleen Makowski | 3.3.16
Florida
Florida Consumer Group And Union Comments to Florida Insurance Commissioner Kevin McCarty | 12.17.15
Georgia
Georgia Consumer Group Comments to Georgia Office of Insurance and Safety Fire Commissioner Ralph T Hudgens | 6.28.16
Illinois
Illinois Consumer Group and Union Comments to Illinois Director Anne Melissa Dowling | 2.23.16
Indiana
Indiana Consumer Group and Union Comments to Indiana Commissioner of Insurance Stephen Robertson | 4.25.16
Iowa
Iowa Consumer Group and Union Comments to Iowa Commissioner of Insurance Nick Gerhart | 4.8.16
Missouri
Missouri Consumer Group Comments to Missouri Director of Insurance John M Huff | 5.9.16
New York
New York Consumer Group and Union Comments to Acting Superintendent Maria T. Vullo | 3.4.16
Ohio
Ohio Consumer Group and Union Comments to Ohio Lieutenant Governor/Director Mary Taylor | 2.10.16
Virginia
Virginia Consumer Group and Union Comments to Virginia Insurance Commissioner Jacqueline Cunningham | 1.11.16
Wisconsin
Wisconsin Consumer Group and Union Comments to Wisconsin Commissioner of Insurance Ted Nickel | 3.21.16

Fact Sheets
What Mergers Mean for Consumers
If Mergers Are Allowed: State Impact
INFOGRAPHIC: Merger Impact Map
Overview: U.S. Health Insurance Market

ANALYSIS: Accumulator adjustment programs lead to surprise out-of-pocket costs and nonadherence | 2016 Migliara
WHITE PAPER: The Problems of Health Insurance Merger Remedies | 2016 Balto
STUDY: Bigger Is Not Better: Proposed Health Insurance Mergers are Likely to Harm Consumers and Taxpayers | 2016 Spiro, Calsyn, & O'Toole
STUDY: Paying a Premium on Your Premium? Consolidation in the U.S. Health Insurance Industry | 2012 Dafny, Duggan & Ramanarayanan
STUDY: The Price Effects of a Large Merger of Health Insurers: A Study of UnitedHealth-Sierra | 2013 Guardado, Emmons & Kane
Supplement: Health Insurance Mergers |The Vital Role of State Insurance Commissioners in Investigating Anthem-Cigna and Aetna-Humana
Studies & White Papers

2.19.19
Comment letter to DOJ from Medical, Consumer, and Advocacy Organizations 6.28.16
Comment letter to DOJ from California Insurance Commissioner Dave Jones 6.16.16
Comment letter to Florida Attorney General from Florida Campaign For Consumer Choice 5.5.16
Comment letter to U.S. Department of Health and Human Services from American Hospital Association 5.2.16
Comment letter to Indiana Department of Insurance from Indiana State Medical Association 4.29.16
Comment letter to California Department of Insurance from Consumers Union 4.25.16
Comment letter to DOJ from the American Hospital Association 4.18.16
Comment letter to California Department of Insurance from California Medical Association 4.1.16
Comment letter to Wisconsin Office of the Commissioner of Insurance from State Representative Eric Genrich and State Senator Dave Hansen 3.28.16
Comment letter to California Department of Insurance from Consumer Watchdog 3.28.16
Comment letter to California Department of Insurance from Health Access California 3.25.16
Comment letter to Connecticut Insurance Department from Connecticut Campaign for Consumer Choice 3.22.16
Comment letter to Wisconsin Office of the Commissioner of Insurance from Consumer Action, Consumers Union, Citizen Action of Wisconsin, SEIU Healthcare Wisconsin, Consumer Federation of America, US PIRG, WISPIRG, Wisconsin Jobs Now, Coalition of Wisconsin Aging Groups, Wisconsin AFL-CIO, ABC for Health, Wisconsin Federation of Nurses and Health Professionals, American Federation of State, County, and Municipal Employees, National Association of Social Workers, Wisconsin Chapter, 9to5 Association of Working Women, Wisconsin, Wisconsin Farmers Union, and National Alliance on Mental Illness Wisconsin 3.21.16
Comment letter to California Department of Managed Health Care From California Medical Association 3.16.16
Comment letter to Connecticut Insurance Commissioner from Connecticut State Legislators 3.11.16
Comment letter to California Department of Managed Health Care from Health Access California 3.11.16
Comment letter to California Department of Managed Health Care From Consumer Watchdog 3.4.16
Comment letter to DOJ from the American Hospital Association 2.29.16
Comment letter to Illinois Attorney General from the Illinois Health and Hospital Association 2.8.16
Comment letter to Illinois Department of Insurance from the Illinois Health and Hospital Association 2.8.16
Comment letter to Kansas Attorney General from the Kansas Hospital Association 1.16.16
Comment letter to Kansas Insurance Department from the Kansas Hospital Association 1.15.16
Comment letter to California Department of Manged Health Care from Health Access California 1.11.16
Comment letter to California Department of Manged Health Care from Consumer Watchdog 1.11.16
Comment letter to California Department of Managed Health Care from Consumer Action 1.11.16
Comment letter to DOJ from the American Antitrust Institute 1.11.16
Comment letter to DOJ from the American College of Physicians 12.3.15
Comment letter to New Hampshire Governor from the New Hampshire Hospital Association 11.9.15
Comment letter to DOJ from the Texas Medical Association 10.6.15
Comment letter to DOJ from the American Psychiatric Association 9.9.15
Comment letter to DOJ & HHS from the American Hospital Association 9.1.15
Comment letter to DOJ from the American Academy of Family Physicians 8.28.15
Comment letter to DOJ from Healthcare Providers 8.13.15
Comment letter to DOJ from the American Hospital Association 8.5.15
Letters

"Public Hearing on the Proposed Merger on Anthem, Inc. and Cigna Corporation"
Virginia State Corporation Commission Hearing on Anthem-Cigna 5/25/16
"In the Matter Of: Acquisition of Control of: Cigna Healthcare of Indiana"
Indiana Department of Insurance Hearing on Anthem-Cigna 4/29/16
"Hearing to Elicit Testimony and Comments Regarding the Possible Implications of the Proposed Merger between Humana, Inc. and Aetna, Inc"
California Department of Insurance Hearing on Aetna-Humana 4/27/16
"Hearing to Elicit Testimony and Comments Regarding the Possible Implications of the Proposed Merger between Anthem, Inc. and Cigna Corporation"
California Department of Insurance Hearing on Anthem-Cigna 3/29/16
"Healthy Competition? An Examination of the Proposed Health Insurance Mergers and the Consequent Impact on Competition"
House Judiciary Subcommittee Hearing 9/25/15
"Examining Consolidation in the Health Insurance Industry and its Impact on Consumers"
Senate Judiciary Subcommittee Hearing 9/22/15
"The State of Competition in the Health Care Marketplace"
House Judiciary Subcommittee Hearing 9/10/15
Congressional &
State Hearings
Past Enforcement Actions
United States v. Aetna (1999) Summary: Merger of Aetna and Prudential, two of the largest insurance companies in 1999. The competitive concerns were in overlaps between the parties' HMO and POS plans. While the most significant overlaps were found in Texas, the DOJ was also concerned about the combined "purchasing power" of the parties to "depress physicians' reimbursement rates." The merger was allowed, but the DOJ required the parties to divest HMO plans in Houston and Dallas.
United States v. UnitedHealth (2005) Summary: Merger between dominant insurers UnitedHealth and PacifiCare. Both insurers sold HMOs and PPOs in a number of different states. The DOJ's investigation focused on mainly Arizona and Colorado. Merger was consummated, but the parties were forced to divest all commercial health insurance in Tucson, AZ and Boulder, CO. United was also forced to terminate its "network access agreement with Blue Shield of California."
United States v. UnitedHealth (2008) Summary: Merger between UnitedHealth and Sierra Health. Sierra's main focus was Medicare Advantage plans, but was also the largest insurer in the State of Nevada. The combined United and Sierra would have had a 94% market share for Medicare Advantage enrollees in Las Vegas. DOJ forced the parties to only divest Sierra's Medicare Advantage portfolio.
Independence Blue Cross and Highmark's failed merger (2009) Summary: The merger of Independence and Highmark would have created an entity with 73% market share in Pennsylvania. The Pennsylvania Insurance Department opposed the merger, and in 2009 the parties dropped their plans to merge.
Blue Cross Blue Shield of Michigan and Physicians Health Plan of Mid-Michigan failed merger (2010) Summary: Blue Cross had a 70% market share while PHP had a 20% market share and controlled the largest hospital system in the state of Michigan. After the DOJ threatened to file suit to prevent the merger, the parties abandoned the transaction.
United States v. Humana (2012) Summary: Merger between Humana and Arcadian Management Services. Both parties primary business is through Medicare Advantage plans. The DOJ concluded that there were significant overlaps in five different states-- Arizona, Arkansas Louisiana, Oklahoma, and Texas. The parties were allowed to merge, but they were required to divest Arcadian's Medicare Advantage plans in 51 counties throughout the five states.
United States v. WellPoint (2012) Summary: Merger between WellPoint, acquired by Anthem in 2004, and Amerigroup. Amerigroup specialized in Medicaid Managed Care products. The DOJ allowed the parties to consummate the merger, but required Amerigroup to sell its Medicaid Managed Care plans in Northern Virginia.
